Evolution of a Specialty: From Proceduralist to Practitioner.

HomeRadiologyVol. 308, No. 1 PreviousNext Reviews and CommentaryFree AccessEditorial–Centennial ContentEvolution of a Specialty: From Proceduralist to PractitionerJeanne M. LaBerge Jeanne M. LaBerge Author AffiliationsFrom the Department of Radiology, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628.Address correspondence to the author (email: [email protected]).Jeanne M. LaBerge Published Online:Jul 25 2023https://doi.org/10.1148/radiol.230226MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In See also the editorials by Marx and Weiss and Hafezi-Nejad in this issue.IntroductionAs I write this editorial for the centennial of Radiology, I am happy to note that interventional radiology (IR) is a thriving specialty. IR doctors deliver life-saving care to patients, provide highly valued ancillary support services to their medical and surgical colleagues, and are an essential component of modern inpatient hospital care.The key to the success of IR has been an ability to adapt and change with the times. Interventional radiologists are typically “early adopters” and have been quick to embrace new imaging and procedural techniques to improve their practice. As IR procedures became more complex over time, interventional radiologists have taken the initiative to incorporate periprocedural clinical care into their practice to provide optimal patient care.Going forward, the specialty of IR will certainly continue to evolve as it adapts to new circumstances and conditions. Future IR leaders will need to keep up with these patient-centered changes and formally incorporate them into the practice of IR. I have had the privilege to observe and usher in many changes in the specialty over my 30-year career in my roles as a trustee of the American Board of Radiology (ABR) and a member of the Radiology Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME). My hope in this editorial is to explain how and why change has happened in IR so that future leaders can benefit from the experience and insights of their predecessors.The Origin of IRTwo seminal events marked the origin of IR. The first occurred in 1953 when Sven-Ivar Seldinger conceived of a percutaneous approach for diagnostic vascular imaging (later termed the Seldinger technique). The second occurred in 1964 when Charles Dotter demonstrated that this same percutaneous approach could also be used for therapeutic purposes when he introduced the concept of transluminal angioplasty (1,2).A Brief Recap of the Evolution of IR (1964–2014)During the intervening 60 years, interventional radiologists have gradually evolved from proceduralists to practitioners. This evolution necessarily started first at the grassroots level with individual practitioners implementing changes to their practice. Subsequently, many of these changes were accepted and codified at the level of organized medicine. Hence, a brief history of the evolution of IR may be useful to the reader.From 1964 to 1994, IR emerged as a subdivision of diagnostic radiology (DR), first under the name of “special procedures” and then “interventional radiology.”In 1994, IR became officially recognized as a subspecialty of radiology by the ABR, and the ACGME established a 1-year vascular and IR fellowship training.In 2000, the Society of Interventional Radiology created a voluntary pathway in which residents receive a year of training in clinical care specialties during residency.In 2005, the ABR approved a voluntary alternate DIRECT (Diagnostic and IR Enhanced Clinical Training) pathway that provided a path for residents transferring in from other clinical specialties.In 2009, the ABR submitted a proposal to the American Board of Medical Specialties (ABMS) for certification of IR as a specialty that did not provide full training in diagnostic imaging and was rejected by the ABMS.In 2011, the ABR resubmitted a proposal for the establishment of the specialty named IR/DR with the incorporation of 3 years of basic DR imaging training followed by 2 years of training in IR with the requirement for a 1-year clinical internship.In 2012, IR/DR was formally recognized as a unique specialty in medicine by the ABMS.In 2014, the ACGME approved a new training program for the specialty.The impetus for the changes made from 2000 onward was twofold. First, the number, variety, and complexity of IR procedures had expanded. These procedures included arterial, venous, and portal venous vascular procedures and a diversity of nonvascular procedures including abdominal drainages, complex liver and biliary procedures, genitourinary interventions, and thoracic interventions. Over time it appeared harder for residents to acquire the necessary skill set to independently perform all of these procedures after a 1-year fellowship.Second, and perhaps more importantly, over the course of the 1990s the essential role that periprocedural care (care before and after an IR procedure) played in IR became apparent and was the main driver for codifying change. As IR procedures became more complex, preprocedural and consultative care became a necessary component for the safe and effective practice of IR. Complex procedures such as transjugular intrahepatic portosystemic shunt placement, uterine artery embolization, and radioembolization required preprocedural evaluation and consultation with patients. Such patients also required follow-up evaluation and management, which could only be performed by a qualified interventional radiologist.The Emergence of IR/DRIn recognition of the important changes in the practice of IR outlined earlier, in 2012 the ABMS identified the field of IR/DR as a unique specialty in medicine. ABMS approval included the important provision that IR-specific periprocedural care is a required component of IR care. The role of IR in periprocedural care is now recognized and required of all interventional radiologists.The ACGME training program requirements approved in 2014 included additional time for IR-specific procedural training, mandatory training in clinical periprocedural care, and a mandatory clinically oriented 1-year internship (3,4).The IR/DR Certificate and the IR Residency: How Did It Come to Fruition?IR changes emerged from the grassroots—at the level of individual practitioners. Early on, interventional radiologists realized that providing periprocedural care could benefit their patients and they began to play a larger role in providing inpatient and outpatient care. However, to ensure that such periprocedural care is a standard practice within IR, these activities needed to be codified, approved, and accepted by the many organizations that constitute organized medicine.Organized medicine consists of a complex web of independent but interrelated organizations. Some of these organizations represent governing bodies such as the ABMS (ABR) and ACGME (Radiology Residency Review Committee). Some represent stakeholders such as the Society of Interventional Radiology, American College of Radiology, RSNA, and Association of University Radiologists. Some represent administrators, such as Society of Chairs of Academic Radiology Departments, Association of Program Directors in Radiology, and Association of Program Directors in IR. Finally, some provide key implementation functionality, such as the National Resident Match Program, Association of American Medical Colleges, and Electronic Residency Application Service. Moreover, the individuals affected by these changes, namely, practicing interventional radiologists, residents, and medical students, must be kept abreast of developments. To successfully implement changes in the certification and training of IR doctors, all these individuals, organizations, and stakeholder groups must be involved and informed. Such outreach presents a daunting challenge.The new IR/DR specialty certificate and IR training program were ultimately successful. The first full class of IR residents will graduate this year in 2023. Adoption and implementation of a new specialty and training program such as this is an uncommon event in part due to its difficulty. Thus, I will highlight a few key factors that led to the success of this endeavor.Positioning Interventional Radiologists in Leadership Roles within Organized MedicineHaving a seat at the table is essential for communicating concepts and influencing opinions. Our efforts succeeded in large part because interventional radiologists were positioned in key leadership positions throughout organized medicine and, importantly, maintained leadership positions in these key organizations throughout the 2000s.Communication, Outreach, and DialogueOne cannot overstate the challenges of effectively communicating the concept of a new specialty and training program, particularly those as complex as the IR/DR certificate and residency.Two approaches to our IR/DR communications proved particularly effective. The first approach involved using IR leaders positioned in stakeholder organizations to explain and promote these changes (a top-down approach). The second approach involved facilitating communication with medical students and encouraging medical students to disseminate this information to their peers at their home organizations (a bottom-up approach). The value of medical student engagement is huge. If one wants to deliver a message to the academic medical community, medical students are perhaps the most effective means. Engaged medical students can get the word out to authorities throughout the medical center with speed and effectiveness unrivaled by other avenues of communication.Monitoring Ongoing Changes in Health Care and Other SpecialtiesIncorporating major changes into the practice of a specialty can take a long time. For IR/DR, the process took over a decade. During this time, the landscape of health care changed and other specialties modified their practices. Some of the important health care trends that took place in the 2000s included (a) a growing use of ancillary professionals such as nurse practitioners and physician assistants to provide patient care services, (b) the emergence of hospitalists as a subspecialty within medicine, and (c) a trend toward expedited hospital discharge and the use of 23-hour stay.As a result, the details of what periprocedural clinical care means for IR and other like specialties (eg, interventional cardiology, interventional gastroenterology, urology, and vascular surgery) was a moving target in the 2000s. It was a challenge to rigidly define the components of “periprocedural patient care.” In essence, the term connotes the responsibility of interventional radiologists to provide clinical care to patients before and after a procedure that is unique to IR and could not be adequately provided by other physician specialists. In general, this includes performing inpatient and outpatient consultation and evaluation and providing inpatient clinical care with focused longitudinal follow-up. It is expected that interventional radiologists will provide the same type of clinical care provided by other like specialists.Understanding the Value of CompetitionAfter the IR/DR certificate and the IR residency were approved, many stakeholders were reluctant to embrace this change. Although most agreed in principle with the need for change, implementation required considerable time, effort, and expense. To transition to the new residency, each individual training program and medical system had to figure out how to best implement changes based on their own specific institutional situation. In short, the process was a lot of work for doctors already very busy with their many other duties.So how to motivate stakeholders to engage and participate in the process? The answer proved to be old-fashioned competition.Several large programs decided to submit residency applications to the ACGME as early as possible. They were the early adopters. Once their programs were approved, they leveraged that approval to attract applicants. Their logic was that the IR community and Radiology Residency Review Committee had painstakingly devised a training program to enhance a trainee’s ability to optimally care for patients undergoing IR procedures. These early adopters wanted to provide the best training they could for their residents, and they also wanted to attract the best residents.Once an element of competition was introduced, more programs started to submit IR residency applications. Like the early adopters, they also wanted to provide optimal training and attract the best residents.The Most Persuasive Argument: Improved Patient CareThe process of bringing about change to the practice of the medical profession is arduous. Stakeholders at almost every level are generally comfortable with the status quo and resist change. Proposing major changes to the scope of practice or the details of training requirements prompts pushback and raises concerns about unintended consequences (eg, these changes in one specialty might adversely impact another specialty). Airing such discussions is necessary and productive. If opposition to a new program is compelling, the proposals will not succeed.In the end, the most compelling argument in favor of the IR/DR project was that it would improve patient care. Training physicians to competently evaluate and manage their patients before and after procedures seemed the right thing to do. Requiring that IR/DR physicians integrate periprocedural clinical care into their practice seemed the right thing to do. In the end, this is the argument that won the day.ConclusionThe evolution from proceduralist to practitioner was codified by the creation of the new IR/DR certificate and IR residency. But the practice of IR is sure to evolve further in the coming years. Leaders in the field should carefully monitor the state of the specialty and make formal changes as warranted. To this end, interventional radiologists should set the following goals: (a) understand how the world of organized medicine works and use this understanding to facilitate beneficial changes in IR; (b) promote IR leaders to positions of responsibility in key roles throughout organized medicine; (c) maintain communications and obtain feedback from key stakeholders (in particular, listen to interventional and diagnostic radiologists and radiologists in practice and respond to grassroots changes); (d) pursue outreach with medical students, who are the future of medicine and IR; (e) encourage the natural tendency of academic institutions and departments to compete in the quest for improved patient care; and (f) most importantly, before making any changes, keep the best interests of patients at center stage and work with stakeholders to improve patient care.In this special centennial issue on IR, please see the commentaries by Marx (5) and Weiss and Hafezi-Nejad (6). I also refer the reader to the articles by Elsayed and Solomon (7), Brock et al (8), and Almansour et al (9).Disclosures of conflicts of interest: J.M.L. Consultant for Bard Peripheral Vascular; board member on the IVC Filter Study Group.References1. Seldinger SI. Catheter replacement of the needle in percutaneous arteriography; a new technique. Acta Radiol 1953;39(5):368–376. Crossref, Medline, Google Scholar2. Dotter CT, Judkins MP. Transluminal treatment of arteniosclerotic obstruction: description of a new technic and a preliminary report of its application. Circulation 1964;30:654–670. Crossref, Medline, Google Scholar3. Kaufman JA. The interventional radiology/diagnostic radiology certificate and interventional radiology residency. Radiology 2014;273(2):318–321. Link, Google Scholar4. LaBerge JM, Anderson JC; Radiology Review Committee. A guide to the Interventional Radiology residency program requirements. J Am Coll Radiol 2015;12(8):848–853. Crossref, Medline, Google Scholar5. Marx MV. Interventional Radiology: Reflections and Projections. Radiology 2023;308(1);e230174. Google Scholar6. Weiss CR, Hafezi-Nejad N. Interventional Radiology: Past, Present, and Future. Radiology 2023;308(1):e230809. Google Scholar7. Elsayed M, Solomon SB. Interventional Oncology: 2043 and Beyond. Radiology 2023;308(1);e230139. Link, Google Scholar8. Brock KK, Chen SR, Sheth RA, Siewerdsen JH. Imaging in Interventional Radiology: 2043 and Beyond. Radiology 2023;308(1);e230146. Link, Google Scholar9. Almansour H, Li N, Murphy MC, Healy GM. Interventional Radiology Training: International Variations. Radiology 2023;308(1);e230040. Link, Google ScholarArticle HistoryReceived: Feb 6 2023Revision requested: Feb 10 2023Revision received: Mar 1 2023Accepted: Mar 2 2023Published online: July 25 2023 FiguresReferencesRelatedDetailsCited ByInterventional Radiology: Past, Present, and FutureClifford R. 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